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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#' / SERVICE REQUEST# <br /> wal -q s(zDC� 79�� 1 <br /> OWNER/OPERATOR <br /> A•pS"-T ��`M' I ��al CHECK If BILLING ADDRESS� <br /> FACILITY NAME VV\ VVAbV-C �`Ol I pt �JCu^1 <br /> SITE ADRdcl�T ADDRESS S T rh C1$ 2a3 <br /> v <br /> Sheet Number DirJection Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 7 USheet Number _ V ti wrw <br /> h Street Name <br /> CITY STATE ZIP <br /> S TOC lcluH (f� °`IS2oG <br /> PHONE#1 EItT' APN# LAND USE APPLICATION# <br /> (79) - 2- 41 - 6z t -1 13S NlCC5 <br /> PHONE#2 EaT• BOS DISTRICT LOCATION CODE <br /> ( ) C� o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> •"G> <br /> q`A{✓ I � t. CHECK It BILLING ADDRESS <br /> N C/' PHONE# EZT' <br /> Y <br /> BUSINESS NAME b W Pc o�,� ,��Cwl, . ?- <br /> HOME or MAILING ADDRESS FAx# <br /> Z'?•of S fjayk ILA r 7 ( ) <br /> CITY S To C \o N 6A STATE ZIP O(S 6 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> acknowledge that all Site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: O <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 it is available and at the Sam�tiryq jt��p[gv,(�d to me or <br /> my representative. �F•+'/A•�Y M�CPP�I�� <br /> TYPE OF SERVICE REQUESTED: KEGEIVED <br /> COMMENTS: JUL it O 2018 <br /> �t 9 4f, o �/7 eI^ SAN JOAQUIN COUNTY <br /> _ <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT, <br /> ACCEPTED BY: EMPLOYEE#: DATE: '7 <br /> ASSIGNED TO: 0 Ch UJ 7-- EMPLOYEE M DATE: -7 <br /> Date Service Completed (if aireadycompleted): SERVICE CODE: D(9 PIE: <br /> Fee Amount: lG1'a00 Amount Paid SIL — Payment Date 7• � • <br /> Payment Type �4 5(� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />